Policies, Procedures, Guidelines and Protocols Title Trust Ref No 1549-36354 Local Ref (optional) Main points the document covers Who is the document aimed at? Author Approval process Document Details Professional Registration Policy and Procedure N/A This policy details the processes to be followed in respect of professional registration. All professionally qualified clinical staff Tracey Neal, Senior HR Advisor Who has been consulted Joint Negotiating Partnership in the development of this policy? Approved by HR & Workforce Group (Committee/Director) Approval Date 9 th December 2015 Initial Equality Impact Screening Full Equality Impact Assessment Lead Director Category Sub Category Yes No Director of Corporate Affairs Human Resources Workforce Review date 9 th December 2018 Distribution Who the policy will be distributed to Method Document Links Required by CQC Other Amendments History To senior staff as defined by Directors for cascading Publication on the Trust Intranet No None No Date Amendment 1 September 2015 Paragraph numbers added, section 2.1 updated, addition of section 4.3 Nursing Midwifery Council, removal of compliance monitoring table and replaced with paragraph 11.2.1, removal of agency pro-forma as included in Safer Recruitment Policy. 2 May 2017 Added additional line manager and staff responsibility regarding notification of third party/self-referrals to regulatory body (3.3 and 3.4).
Contents 1 Introduction... 3 2 Purpose and Scope... 3 2.1 Agency and Locum Workers... 4 3 Duties... 4 4 Procedure for Checking Professional Registration... 5 4.1 New Employees... 5 4.2 During Employment... 5 4.3 Nursing & Midwifery Council... 6 5 Failure to Comply... 6 5.1 Guiding Principles... 6 5.2 Process to Follow in Respect of Unregistered Professionals... 7 6 Notices from Professional Registration Bodies... 8 7 Audit... 8 8 Related Documents... 8 9 Dissemination... 9 10 Advice... 9 11 Policy Review and Compliance Monitoring... 9 11.1 Policy Review... 9 11.2 Compliance Monitoring... 9 Appendix 1 - Contacting Professional Regulatory Bodies... 10 Appendix 2 - Confirmation of Renewed Registration... 11 Appendix 3 - Template Letter for Lapsed Registration... 12 Page 2 of 12
1 Introduction 1.1 All professionally qualified clinical staff must, by law, register with the appropriate regulatory body. In order to ensure all professional clinical staff are appropriately registered to undertake the posts to which they have been appointed, individuals will be required to provide evidence of their registration prior to commencement of employment and during their employment with the Trust. 1.2 In order to protect patients, no professional member of staff will be allowed to work in a professional capacity unless fully qualified and registered with the appropriate regulatory body. 1.3 The requirement for professional registration for any particular post will be identified in the person specification. It is a contractual condition that the healthcare professional has appropriate registration throughout their employment. 1.4 Registration details will be recorded on the Trust s Electronic Staff Record (ESR) and this will provide alerts to line managers and the Recruitment Team of registrations due to lapse or lapsed. The Trust will monitor registrations by regular monthly checks on ESR, and cross reference against registration body websites. 2 Purpose and Scope 2.1 The purpose of this policy is to ensure that adequate and reliable procedures are in place to assist managers in their responsibilities. By complying with the policy the Trust will help to safeguard patients and clients from professional bad practice or misconduct. 2.2 This policy and procedure applies to all staff groups who are professionally registered including temporary staff (fixed term, agency, locum) and applies to the following: Regulatory Body General Dental Council (GDC) www.gdc-uk.org General Medical Council (GMC) www.gmc-uk.org General Pharmaceutical Council (GPhC) www.pharmacyregulation.org General Social Care Council (GSCC) www.gscc.org.uk Health and Care Professions Council (HCPC) www.hpc-uk.org Nursing & Midwifery Council (NMC) www.nmc-uk.org Staff Groups Covered Dentist, clinical dental technician, dental nurse, dental hygienist, dental technician, dental therapist, orthodontic therapist Doctors Pharmacists and Pharmacy Technicians Social Workers and Student Social Workers Arts Therapists, Biomedical Scientists, Chiropodists, Podiatrists, Clinical Scientists, Dieticians, Occupational Therapists, Orthoptists, Paramedics, Physiotherapists, Psychologists, Prosthetists, Orthotists, Radiographers, Speech and Language Therapists Nurses, Midwives and Health Visitors Page 3 of 12
2.1 Agency and Locum Workers 2.1.1 Workers who are not employed by the Trust but who nevertheless are engaged to cover work in the above posts must hold current registration. 2.1.2 Where agency or locum staff are engaged to work for the Trust written confirmation must be obtained from the agency that the worker has appropriate current professional registration, and that there are no restrictions or conditions attached to the registration. 2.1.3 In all cases, if proof of current registration cannot be supplied, the agency or locum worker should not be engaged to work. 3 Duties 3.1 Executive Director of Nursing & Operations Responsible for ensuring any notices/circulars received from professional bodies concerning professional conduct are disseminated promptly to appropriate line managers. 3.2 Recruitment Team will undertake all pre-employment checks including a physical check of professional registration with regulatory body websites. In addition they will record and maintain professional registration details on ESR, and ensure that regular reports are sent to line managers notifying them of registrations due to lapse or lapsed. 3.3 Line Managers are responsible for:- Checking any notices or circulars against current staffing lists to ensure that staff that appear on such lists are identified and appropriate action taken. Such records should also be shared with Recruiting Managers for recruitment purposes. Ensuring that all staff (as appropriate) are aware of their responsibilities under this policy. Ensuring they see original documentation relating to renewed registrations (certificates/pin numbers, print-outs from appropriate regulatory body websites) and sign, date and retain copies of renewed registration documents on the individual s personnel file. Informing the Recruitment Team of renewed or amended registrations in order that the Electronic Staff Record can be updated (Appendix 3 can be used for this). Contacting the Human Resources department and the Director of Operations If a member of staff discloses that they are the subject of either a third party referral or self-referral to their regulatory body. 3.4 Employees are responsible for: Familiarising themselves with this policy and procedure. Registering with the appropriate professional body. Ensuring that they have received the details of their registration PIN number/registration certificate. Ensuring the registration body s records are correct in respect of their registration. Page 4 of 12
Page 5 of 12 Ensuring that both the registration body and immediate line manager have an up to date record of registration. Ensuring that both the registration body and immediate line manager are notified of any changes in registration status. The payment of any fees required for registration. Ensuring registration is obtained and renewed within specific timescales laid down by the registration bodies. Abiding by their code of conduct at all times. Immediately bringing it to the attention of their Line Manager if they become subject to either a third party referral or a self-referral to their regulatory body. 3.5 It is the individual s responsibility to ensure registration is effective at all times of employment with the Trust including during extended periods away from the workplace e.g. maternity, paternity and adoption leave, career breaks. 3.6 Failure to re-register and to continue in practice is against all professional codes and can be viewed as professional misconduct by employers and regulatory bodies. In addition staff are expected to adhere to the Trust s clinical strategies on clinical supervision. 4 Procedure for Checking Professional Registration 4.1 New Employees 4.1.1 The Recruitment Team (RT) will carry out a registration check with the appropriate registration body as detailed in the person specification prior to commencement. The registration check will involve: Confirming that the applicant is registered to carry out the role. Whether the applicant s registration is subject to current restriction which might affect duties proposed. Confirming if the prospective employee has investigations against them about their fitness to practice. 4.1.2 The RT will check the registration certificate/pin card/statement of entry and regulatory website to ensure that it is appropriate for the post and that all registrations are valid. Copies of the following documents will be held on the individual s personnel file and details entered on to ESR. The professional registration certificate Statement of entry on to Register PIN card (both sides) Printout from Regulatory Body website 4.2 During Employment 4.2.1 It is the responsibility of all professional staff to ensure they keep their registration valid and that all fees are paid before their registration is due to expire. 4.2.2 The RT will send reports to line managers on a monthly basis detailing those employees whose registration is due to expire shortly.
4.2.3 Line managers should remind their member of staff that the renewal is due, and that they must provide evidence of renewal. Line managers should ensure they see original documentation of the renewal, obtain a print-out from the regulatory body s website and retain signed and dated copies confirming they have seen original documentation in personal files. 4.2.4 Line managers must notify the RT that they have seen documentation to confirm renewal and confirm when the new expiry date is. Appendix 2 should be used to enable central data collection and updating of Electronic Staff Record (ESR). 4.3 Nursing & Midwifery Council 4.3.1 The NMC have removed the short administrative window in which late submissions from nurses and midwives were processed without requiring them to apply for readmission. The NMC write to individuals 45 days in advance to advise when registration renewal is due. 4.3.2 If you don t submit your documentation or fees before your due date your registration will automatically lapse and you will be unable to practice. From November 2015 should you allow your registration to lapse the only way to regain registration will be by applying for readmission. That process can take two and six weeks depending on the circumstances and during this time you would be unable to practice. 4.3.3 Continuing to work in a registered role while not on the NMC register contravenes the code and is illegal. 5 Failure to Comply 5.1 Guiding Principles 5.1.1 If an employee is unable to produce evidence of current registration the line manager must ensure that the individual does not continue to practice in a registered capacity until such time as written evidence of current registration is produced. 5.1.2 Depending on the circumstances of the situation the line manager should consider a range of options which could be, allowing the individual to work in an unregistered capacity (or lower band) with commensurate level of pay, moving the individual to another area of work (e.g. admin/reception) or suspension without pay. 5.1.3 In such instances the line manager should contact Human Resources for further advice. Human Resources will consult with the Executive Director of Nursing & Operations or in their absence their Deputy or the appropriate professional lead prior to a decision being made. 5.1.4 If, whilst working in an unregistered capacity, an individual works at a lower band, and is subsequently unfit for work or takes annual leave, remuneration will be commensurate with the lower band. Page 6 of 12
5.1.5 When considering advice in section 5 checks should be undertaken by the line manager in order to establish the cause for lapse or delay in registration. Registration checks in relation to any of the below situations can be obtained either by telephoning the professional registration bodies confirmation service or by on-line (refer to Appendix 1). 5.1.6 Unregistered professional staff are likely to fall into one of three categories which should be dealt with as follows: Newly registered staff should not be allowed to work in a registered capacity whilst unregistered, and should be paid at an appropriate unregistered band until registration is verified. Unregistered staff due to lapsed membership should work in an unregistered capacity, and will be paid at an appropriate unregistered band until they become re-registered. Unregistered staff due to NMC delay Nursing staff are given prior notice by the NMC that registration is due. Nurses who can prove they have applied to re-register within a reasonable timescale (at least 4 weeks prior to their registration date lapsing) and can prove that delays are beyond their control should not be financially penalised. They should work in an unregistered capacity whilst maintaining their current salary. 5.2 Process to Follow in Respect of Unregistered Professionals 5.2.1 In the event of a lapsed/delayed registration the line manager should consider a range of options to ensure the individual does not continue to practice in a registered capacity. 5.2.2 If an individual's professional registration has lapsed then depending on the circumstances of the situation, the line manager should consider a range of options: allowing the individual to work in an unregistered capacity (or lower band) with commensurate level of pay up to a maximum of 12 weeks. moving the individual to another area of work (e.g. admin/reception) or undertaking mandatory training/e-learning and paid as an unregistered member of staff. Suspension without pay should be a very last resort 5.2.3 In such instances the line manager should contact Human Resources for further advice. Human Resources will then consult with the Director of Nursing & Operations or in their absence their Deputy or the appropriate professional lead for a decision to be made. 5.2.4 The line manager must complete an incident form in each case where nonregistration is discovered and include the reasons for non-registration and any actions taken. Page 7 of 12
5.2.5 The line manager will meet with the individual to review registration status and agree a course of action including timescales. Employees may be supported by a work colleague or staff side (trade union or professional organisation). Discussions and actions relating to lapsed registrations should be confirmed in writing, and a copy kept on the employee s personal file (Appendix 3 should be used and can be adapted to individual circumstances). 5.2.6 If the individual fails to obtain registration within the agreed timescale without a satisfactory reason, acceptable to the line manager, the issue may become subject to the Trust s Disciplinary Policy and could lead to dismissal. 5.2.7 The outcome of any disciplinary action should be notified to the relevant Director for that service. In the event the professional body needs notifying, the Director will liaise with the relevant professional lead in notifying the regulatory body. 5.2.8 When information has been received that re-registration has been successful, the manager will confirm registration and will advise the employee verbally and in writing that they may resume their professional responsibilities and duties. 5.2.9 Payment of salary for the appropriate professional grade will be re-instated from the date that confirmation of valid registration is received by the Trust. Salary will not be backdated to the original expiry date. 6 Notices from Professional Registration Bodies 6.1 On a regular basis the professional registration bodies issue circulars and notices providing information on changes to registration such as cautions, suspension and removal from the register. These notices/circulars are time limited and updated periodically on their respective websites. 6.2 The notices/circulars go to the Recruitment Team who enter the information onto an Alert database and act as a filter. During professional registration checks the database is checked to enable appropriate action to be taken. 7 Audit 7.1 Random checks may be made at anytime and/or as part of the Trust s Internal Audit Programme. 8 Related Documents 8.1 The following Trust documents can be found in the policies and procedures section of the Shropshire Community Health NHS Trust website and should be referred to for related information: Recruitment and Selection Policy (Safer Recruitment) Disciplinary Policy Page 8 of 12
9 Dissemination 9.1 This Policy will be disseminated by being published on the Website and awareness raising by HR and formal staff side representatives. 10 Advice 10.1 Advice on this policy should be sought in the first instance from Human Resources. 11 Policy Review and Compliance Monitoring 11.1 Policy Review 11.1.1 The rules and operation of this policy and procedure will be periodically reviewed (at least every 3 years) in light of any developments at either national policy level, or locally and, if necessary, revised in order to ensure their continuing relevance and effectiveness. Any amendments will be introduced only after consultation with staff-side representatives. 11.2 Compliance Monitoring 11.2.1 The HR team will monitor the processes that underpin this policy, identifying any issues and amend any forms and processes as necessary. These amendments to the policy and relevant supporting documentation will be communicated to manager s who are responsible for implementing improvements where identified. Page 9 of 12
Professional Registration Policy and Procedure Shropshire Community Health NHS Trust Appendix 1 - Contacting Professional Regulatory Bodies Professional regulatory bodies can be contacted via telephone or by accessing their website. Managers who access the website need to be aware that there is usually a transition period of around one week before new or amended registration details are passed to the website. Managers should also ensure registration is applicable to the individual they are verifying details for and therefore will need to have the individual s full name, date of birth and pin/reference number. Staff Group Professional Registration Body and Website Address Telephone Number Dentist, clinical dental technician, dental nurse, dental hygienist, General Dental Council (GDC) dental technician, dental therapist, www.gdc-uk.org orthodontic therapist. Doctors General Medical Council (GMC) Registration Period 0207 887 3800 Yearly www.gmc-uk.org 0161 923 6602 Yearly Social Workers General Social Care Council (GSCC) Student Social Workers www.gscc.org.uk 0845 070 0630 3 Yearly Arts Therapist Biomedical Scientist Chiropodist, Podiatrist Clinical Scientist Health and Care Professions Council 020 7840 9802 2 Years Dietician www.hpc-uk.org Occupational Therapist Orthoptist, Paramedic Physiotherapist Psychologists Prosthetist and Orthotist Radiographer Speech and Language Therapist Nurses, Health Visitors and Midwives Nursing & Midwifery Council (NMC) www.nmc-uk.org 0207 637 7181 Yearly Professional Registration Policy and Procedure V1.2 May 2017 Page 10 of 12
Professional Registration Policy and Procedure Shropshire Community Health NHS Trust Appendix 2 - Confirmation of Renewed Registration Name: Date of Birth: Personal No: Name of Professional Regulatory Body Professional Identification Number (P.I.N.) or Membership Number I confirm that I have examined original documentation and have obtained a print-out from the regulatory body website. I can confirm the above named is eligible to practice on (*as applicable) *Part(s) of the Register (if applicable) Expiry Date Line Manager Signature Date Please send to The Recruitment Team, Corridor J, William Farr House, Mytton Oak Road, Shrewsbury. SY3 8XL Recruitment Team Use Only Entered onto ESR by: Date Professional Registration Policy and Procedure V1.2 May 2017 Page 11 of 12
Professional Registration Policy and Procedure Shropshire Community Health NHS Trust Appendix 3 - Template Letter for Lapsed Registration Dear Reference - Professional Registration Further to our meeting on (insert date) with yourself and (TUPO representative / work colleague), I write to confirm that your registration has lapsed as of (insert date). We discussed the reasons for the lapse in registration, which you gave as (insert reasons). I explained that a condition of your employment with the Trust is that your registration is kept current. In light of the above it is with regret that I confirm that (insert agreed action following reference to section 5 until your registration has been confirmed). You agreed to rectify the situation as a matter of urgency and to confirm your registration status to me by (insert date). Failure to obtain registration within this timescale without a satisfactory explanation may mean that the issue becomes subject to the Trust s disciplinary policy. If you wish to discuss the contents of my letter please do not hesitate to contact me. Yours sincerely Line Manager Copy: Personal File Human Resources Department TUPO Representative (if appropriate) Professional Registration Policy and Procedure V1.2 May 2017 Page 12 of 12